Saturday, February 26, 2011

Conditions & More running related problems

I had  planned on doing the next post on overuse injuries but I have decided to switch to another running related condition.  The conditions is Atrial Fibrillation and Atrial Flutter and it affects many distance runners and especially older ultra runners, like me.

AF is the most common cardiac arrhythmia (abnormal heart rhythm), and involves the two upper chambers (atria) of the heart. Its name comes from the fibrillating (i.e., quivering) of the heart muscles of the atria, instead of a coordinated contraction. It can often be identified by taking ones pulse and observing that the heartbeats do not occur at regular intervals. Risk of atrial fib increases with age, with 8% of people over 80 having AF.  This 8% figure includes everyone, not just runners.
In AF, the normal electrical impulses that are generated by the sinoatrial node, located in the right atrium, are overwhelmed by disorganized electrical impulses that originate in the pulmonary veins located in the left atrium, leading to conduction of irregular impulses to the ventricles that generate the heartbeat. The result is an irregular heartbeat, which may occur in episodes lasting from minutes to weeks, or it could occur all the time for years. The natural tendency of AF is to become a chronic condition. Chronic AF leads to a small increase in the risk of death.  The increased risk of death is because the irregular heart beat can cause blood to pool in the atria and can lead to blood clots.  The clotting occurs primarily in people with a weaker heart than a runner.  The runners heart pumps so strongly that blood does not pool, (usually).  The source of the problem is, as mentioned in the previous paragraph is the pulmonary veins.  The four pulmonary veins enter the left atrium (upper chamber of the heart) from the back side of the heart.  If I have a correct understanding of human anatomy, these vanes lay directly against the esophagus which can create a problem in itself that I will discuss in a minute.  The Vegas Nerves travel along the esophagus.  You probably know that distance runners have larger hearts than the average human and therein lies the problem.  An enlarged heart creates more pressure  against the esophagus and against the Vegas Nerves.  Sometimes the electrical impulses are picked up by the cells in the pulmonary veins and are carried into the heart.

My tracings looked a lot more like this bottom strip but with the irregular spacing from the first diagram.

I have had a heart rhythm problem most if my life.  I remember running in high school and feeling what I called "heart flutters" because that is what it felt like.  They occurred very rarely and seemed to cause no problems so I just ignored them.  This caused no problems until I entered a "sort of" adventure race in Wetumpka, Alabama called the Coosa Challenge.  It consisted of a 800 yard run followed by an 18 mile mountain bike segment, followed by a mile run to the Coosa River.  Then we hoped  on sit-on kayaks for a 4 mile, mostly flat water paddle (there was one good class III section)  and ended with a 5 mile run back to town.  It was a very hot early September day and following the bike ride I grabbed a "Red Bull" sitting in a barrel of ice and gulped it down.   Within seconds I could not get enough air and my heart was doing somersaults.  I thought I might be dying.  I had to walk the mile down to the river and didn't paddle very fast for a while. (Obviously, I wasn't very concerned about dropping dead on the trail.)  By the time I finally reached the takeout I felt better and thought I might be able to run to the finish.  By this time the temperature was close to 100 and there at the takeout was another barrel of Red Bulls.  I took one big drink and once again I felt like I was dying.  This time I realized it had to be the Red Bull so I threw it away.  I walked all the way to the end of the race. 

The same thing happened another time, this time drinking a "Powerade."  I was still blaming the problem on what I was drinking.  Finally in 2008, running the Imogene Pass Run, one of my favorite all time runs, I grabbed a cup of cold water at Lower Camp Bird aid station.  The same symptoms hit almost instantly and I knew the trouble was cold liquid.  It still made no sense to me, but that had to be it.  By 2009 I was having trouble finishing almost every run and race without having to walk for at least an hour while my heart settled back down.  Even then I had to run very slow and never uphill or it would start again.   I gave up and in 2010 went to a cardiologist.  He explained the  problem was atrial flutter and fibrillation.  He said we can try to control it with drugs, but if the AF usually occurs when running, I might just have to change my life style. Instead of changing my lifestyle, I changed cardiologist.  I also asked him why the AF happened when I drank cold water.  He informed that there was not connection, it was just a coincidence.  I knew that was not correct.  I contacted a friend and fellow trail runner who is a retired vascular surgeon to see if he had any suggestions.

I had to add a few pictures from the Imogene Pass Run.  First in about 1,000 feet below the summit, the second is the summit.  The third is a Tom Boy Road as it winds along a cliff band headed down into Telluride.

It just so happens that my friend had developed Atrial Fib not long before and had the atrial ablation procedure done.  His AF was now totally gone.  He suggested I see the cardiologist that performed his procedure, Dr Kay at the University of Alabama at Birmingham, Medical Center.  He told me that UAB Medical Center was one of the three top cardiology centers in the US and that Dr Kay was the best.  I went to see Dr Kay and he put me a drug called Flecianide.  For much of the last three years I have had to constantly deal with AF.  Every time I ran I had to try to keep my level of exertion and my heart rate very low or I would trigger the AF. That was almost impossible, especially running hill repeats. The new drug worked great and since the first if this year I have been able to run as hard as my legs will carry me.  But I do not intend to take a drug for the rest of my life and the Flecianide was not perfect.  I still had AF episodes occasionally, like during the Mercedes Marathon, and there are other side effects as well.  We decided on the Atrial Ablation Procedure.  The procedures involves running a catheter up through Iliac vein into the Inferior Vina Cava into the right atrium.  Small punctures are made in the groin, arm, or neck area and thin, flexible tubes, called catheters, are inserted and threaded to the heart. Once there, the catheter's tip is threaded through a tiny incision in the wall between the left and right atria (septal wall), and is positioned to ablate tissue around the pulmonary veins or at other sources of erratic electrical signals that cause the irregular heartbeat

 Dr Kay started the procedure about noon Thursday and it took a couple of hours.  I was been back in my room by 3:30 and wide awake awake by 5:00 pm.  I feel great after the procedure and we went home Friday morning.  I had intended to work some Friday but I ended up laying around and sleeping most of the day, although we did go out to eat Friday Night.  Today I feel like I could go out and run hill repeats.  My wife will not even allow me to carry a bag of groceries up the stairs.  The Left Atrial Ablation procedure is not 100% successful.  I will know in about 6 weeks, when the scar tissue if completely formed, if the procedure worked.

I just wanted to make everyone aware that atrial fib can be a side effect of running.  The more years you run the greater the risk, especially running ultras.  And beware of gulping down ice cold liquids when you are very hot.  Dr Kay explained that because the Vegas Nerves lay against the esophagus the nerves can be shocked by a sudden change in temperature and can cause the electrical impulses to interfere with regular heart rhythm even if you do not suffer from atrial fib.

Would I do it any different if I could back up about 30 years knowing I would end up with AF?  Absolutely I would.  I would have started trail running and ultras a long time ago!

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